Balance, reframe, and overcome: The attitudes, priorities, and perceptions of exercise‐based activities in youth 12–24 months after a sport‐related ACL injury

3.1 Participant characteristics

Participant characteristics are summarized in Table 1. Ten youth (six women, four men), a median (range) age of 19 (17–20) participated in the study. The median age of injury was 17.5 (15–18) years, and the median time since injury was 20 (16–26) months. Six participants had a primary ACLR, one had an ACLR revision, and three elected for nonsurgical management. Six participants had returned back to their preinjury sport by one year following ACL tear or ACLR. Of these, four returned to preinjury competitive levels. Three participants were undergoing formal rehabilitation and one was rehabilitating independently. The two participants under 18 years of age did not meet recommended weekly MVPA (420 min per week),34 while all eight participants 18 years or older did (150 min per week).34

Table 1. Participant characteristics Participant alias Cohort follow-up (month) Sex Injury age Interview age Injury type Time from injury (months) Time from ACLR (months) Pre-injury Sport(s) Level of pre-injury sport participationa RTS status (Y/N) b Average weekly MVPA (min)c Boo 18 F 16 17 ACLd 19 - Ringette, Rugby Club Ye 262 Pablo 12 M 18 19 ACL 16 - Ice hockey Club Ye 263 Ella 12 F 18 19 ACLR 17 16 Soccer Varsity Y N/Af Hectorg 18 M 17 19 ACLd 21 - Rugby School N 367 Elevenh 24 F 16 18 ACLR 24 12 Basketball, School N 314 Volleyball Allison 18 F 16 18 ACLRd 20 16 Soccer Provincial Y 404 Rayh 18 M 15 17 ACLRd 24i 24j Football School N 160 Revision Freja 24 F 18 20 ACLR 26 23 Handball National Y 509 Harleyh 12 F 18 19 ACLRd 18 12 Soccer Varsity N 391 Leonard 18 M 18 19 ACLRd 18 16 Ice hockey Club Y N/Af Median (range) 17.5 (15–18) 19 (17–20) (20 –26) 16 (12–24) 341 (160–509) Abbreviations: ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction MVPA, moderate to vigorous physical activity; N/A, not available; RTS, return to sport.

In addition to these 10 individuals, interview invitations were extended to six other individuals (five females, median age at injury of 16.5 years (range 15–19), four with an ACLR and two ACL with nonsurgical management). One participant declined after withdrawing from the cohort study due to time constraints, one declined due to a recent ACL graft tear, and four did not indicate why. There were no interviews that were initiated that were not completed. Sampling ceased after 10 participants when new data did not result in the formation of additional codes or themes and a meaningful description of the clinical reality was possible (Table 1).23

3.2 Themes

Three overarching themes were generated during data analyses (1) balancing physical activity and future knee health; (2) reframing the value of exercise therapy and physical activity; and (3) overcoming unforeseen exercise challenges. The organization of themes are displayed in Figure 1. An overview of each theme is summarized below and in Tables 2–4, with a detailed description and supporting quotes of each presented in Supporting Information S3.

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Overview of data analyses

Table 2. Overview of balance theme and supporting quotes Theme overview Supporting quotes by subtheme

Theme #1: Balancing physical activity and future knee health

The priorities for exercise-based activity participation were to return to some form of sport and maintaining life-long knee health. The priority of a healthy knee was driven by beliefs that current health behavior/actions will facilitate lifelong sport and recreational participation.

Priorities for exercise-therapy

“Right at the start of my career I had this big injury, I wanted to be able to be a good player in the league and get back there. So that was motivating.”

“If I'm continuing to play sports and I want to keep at the level I am, I have to do my physio [exercises] for the rest of my life.”

Negotiating activity choices

“It was a big deal that my injury didn't define me, and that I wasn't going to be done because of an injury, I was going to be done on my own terms…so that was a driving force for me to come back.”

“I definitely want to [go back to basketball]. I think it's kind of hard to say right now, just cause I'm not in the situation of like, ‘make your choice,' [because my knee is not ready]. But I do think I'd go back gradually…I think it'd be kind of, gradual and get comfortable with it…'cause I don't want to rush it. It's my big thing is I don't want to rush it. So just kind of slowly dip my toe in.

“[My knee] is something that [I] need long term. You only get one knee and it ended up just being me having to think bigger than the sport.”

Attitudes about future knee health

“I know I'm probably going to get arthritis…whether, how early I end up going and getting poor arthritis and having problems, I think depends on how much I strengthen it ‘cause I know moving really helps with arthritis. So yeah, I already know that I'll probably end up with arthritis…but it's not a huge concern, ‘cause I already know it's coming no matter what I do.”

“Arthritis is always in the back of my mind …in one or two years if I want to consider doing football again, like [arthritis would] probably be in the back of my head.”

“I think it's just important to maintain those [physio] exercises, even having a Bosu ball at home or having something there that you can just do…even just [using] bands so that you could do little exercises and be like, ‘okay, there's my five minutes [of completing my physio exercises].'”

Table 3. Overview of reframe theme and supporting quotes Theme overview Supporting quotes by subtheme

Theme #2: Reframing the value of exercise therapy and physical activity

Positive reframing of attitudes and perceptions toward exercise-therapy and physical activity help to motivate participation in activities outside of sport including exercise-based rehabilitation.

Attitudes toward exercise-therapy

“I think a lot of times when you're younger and you go through injuries and you have to go through physio and they give you exercises, you're like, ‘ah I don't need to do that, I'm young. I'll bounce back.′ But I think coming off this injury, you have to take it seriously or you'll never feel the same again…I think hard work is definitely the biggest key to that, because if you are not willing to put in the work to get there, then you'll just not ever get there.”

“I had a bad attitude after I hurt it, my knee…now I feel like [exercise therapy and physical activity] are much more important than I thought they were at the time right? I think I would have got to where I wanted – like a better lifestyle if I had taken [exercise therapy] more seriously, but at that point I didn't think [exercise therapy was] important.”

Perceptions about benefits of physical activity

“I mean I didn't think [exercise] was that important until more recently. I'd say probably for over a year after my injury, I did pretty much nothing. Once I got [exercising]…it's pretty easy to [keep] going once you realize that it's very beneficial.”

“Before my injury I would never willingly go to the gym. [But] I had lots of friends, there was six of us that worked out in the summer, every morning at 8 a.m. and it was a reason to go to the gym…Like it wasn't a chore going to the gym, it was just like I'm going to go hangout with them.”

Renewed perspective for physical activity

“[Physical activity is] more important now…– getting that injury you don't realize how much you enjoy all that stuff…you take it for granted almost, so it's nice having a healthy knee again now.”

“I'd say for the most part I enjoyed it [rehabilitation] and I feel I've learned a lot of things that I probably wouldn't have learnt before and I feel it's kind of a blessing in disguise almost. Not that I tore my ACL…I'm more bodily aware. I feel stronger and I know how to properly work out. How to properly eat for my body style and I think that makes me a healthier person, but also a better athlete.”

I think it was a good break for me, I was kind of losing my love for soccer. And I kind of step back for a second. I was able to rehab myself and gain back that love I had [for soccer].

Table 4. Overview of overcome theme and supporting quotes Theme overview Supporting quotes by subtheme

Theme #3: Overcoming unforeseen exercises challenges

Persistent physical and psychological challenges were unforeseen barriers that impeded participation in exercise-based activities. A perception that the knee was able to fully recover influenced participants' willingness to exercise.

Physical challenges to exercise

“Every day is usually different in terms of pain. Like some days I can do stuff [exercises] no problem, other days I have a little bit more issues, so we kind of go on a day-to-day basis.”

“…I still struggle with trying to get rid of weight that I've put on from surgery…it's really tough to come to terms with the fact that as an athlete it's not really that feasible to be ‘oh I'm going to lose weight.′ Because you're doing programs that are supposed to be strengthening.”

Psychological challenges to exercising

“I mean right now I'm just not pushing it that hard. And that's how I'm not re-injuring it, but like I said, I'm hoping at some point here it'll be strong enough. That's how I'm going to prevent re-injuring it, instead of just avoiding [physical activities] entirely.”

“As soon as my knee starts to feel sore, or it doesn't hurt but you can feel it, then I kind of hold back on stuff because I don't want to mess it up.”

In my mind I thought it would be a few months but then that was quickly, ‘like no this is—this is close to a year′…Cause who, who has a yearlong injury at 15? Like that doesn't make a ton of sense.

Perception of recovery

“…it would have been motivating for me if I thought I could recover, but I never thought I could…So it felt like I wasn't really working toward anything…I couldn't be 100 percent [recovered without surgery], I couldn't return to my sport.”

“During the season my knee would be sore, like there'd even be some days I'd be limping a little bit; stuff like that. But I think that was just cause I had [a] hamstring graft. My hamstring would get tight, stuff like that. But now like a year and a half, like no not really [my knee gets sore now while playing].”

“Halfway through the second practice of the day, [I] would start to get a bit sore, but I knew that it was just sore and [there] wasn't actually anything wrong with [my knee].

Experiencing an injury during adolescence milestones

“I never had a major injury like that playing hockey…And I mean who knows…I probably would have been playing Junior A right now if I didn't tear [my ACL].”

“I went back to the team that I played for before and I just wasn't the same player at the start of the year, I needed more time to get into it. So, I got traded…I don't know if it was cause of my knee, there was a new coach in…But…I put in all the work, I should have been a better player, like without the injury. So that was hard, all the work I put in…I wanted to be [better].”

It [was] kind of weird timing for my injury ‘cause it was right as I was graduating high school. So, my life changed as well. I became less active ‘cause I played on three sports teams in high school…so right now I'm busier…I don't really have time for [sport and exercise-therapy].”

The theme most consistently discussed across all participants was ‘balancing physical activity and future knee health.’ Youth reported that their two main priorities for exercise-based activities were returning to any sport and having a “healthy” knee to stay active in the long term. They perceived these priorities as conflicting and described an ongoing negotiation between satisfying their priority of RTS while addressing growing concerns to preserve knee health (i.e., reduce reinjuries or delay future OA). As one participant who returned to their pre-injury sport reported, “[My knee] is something that [I] need long term. You only get one knee and it ended up just being me having to think bigger than the sport,” (Freja).

The risk of developing OA affected how some participants navigated physical activity choices as articulated by Ray, “arthritis is always in the back of my mind …in one or two years if I want to consider doing football again, like [arthritis would] probably be in the back of my head.” Despite this internal struggle, participants generally reported a positive attitude and acceptance toward life-long exercise-therapy knowing that “if I'm continuing to play sports and I want to keep at the level I am, I have to do my physio [exercises] for the rest of my life,” (Boo). Participants also expressed a desire for autonomy to make their own future activity choices.

Literally, physio and stuff like that, I took all [that] stuff with a grain of salt. I'm not saying other people should do that. But I think there's a lot of different professionals and views on your knee, but I know my knee best. It's my body. If I feel comfortable with something, I'm not going to hold back and take three years to nurse my knee…I'm a young athlete so I'm not going to rush it, but I'm not going to take two years [to RTS]. (Leonard).

The second theme, ‘reframing the value of exercise therapy and physical activity', highlighted the evolution of participants' attitudes and beliefs toward exercise-based activities. Most participants reported they maintained or shifted their attitudes toward exercise therapy to be hopeful and optimistic. This was particularly important for participants who were struggling with rehabilitation or had not yet returned to their desired activity level.

Maybe just the thought that…I have to go through all of this to be able to do any sort of physical activity in the future, to be healthy as an adult, I have to go through this. And then, one day you'll be able to do sports. I'd say that was the biggest [thing that keeps me motivated]. (Eleven).

Positive and negative perceptions of exercise-based activities also shaped participants' understanding of the benefits of physical activity. Participants who believed exercise was important also highlighted exercise could alleviate mental stress and provide opportunities to connect with peers. They attributed this positive outlook to maintain their exercise routine and physical activity levels.

I think that when you're physically active, the rest of your life feels like it's organized. If you don't eat properly or you're not working out, you feel sluggish and tired, and you can't accomplish things you want to. So, I think that's [why it's] very important [to be physically activity]. (Ella).

Before my injury, I would never willingly go to the gym. [But] I had lots of friends, there was six of us that worked out in the summer, every morning at 8 am and it was a reason to go to the gym…Like it wasn't a chore going to the gym, it was just like I'm going to go hangout with them. (Allison).

In contrast, negative perceptions of exercise-based activities caused some participants to become more sedentary following their ACL injury. However, these participants reported eventually valuing physical activity after experiencing the benefits of exercising.

I mean I didn't think [exercise] was that important until more recently. I'd say probably for over a year after my injury, I did pretty much nothing. Once I got started [exercising]…it's pretty easy to [keep] going once you realize that it's very beneficial. (Hector).

Perceptions of exercise-based activities were often tied to a renewed perspective on physical activity. Recognizing personal growth from the injury resulted in a more positive mindset and helped participants persevere with their exercise-therapy program and/or develop a new appreciation for physical activity and sport.

I think it was a good break for me, I was kind of losing my love for soccer. And I kind of step back for a second. I was able to rehab myself and gain back that love I had [for soccer]. (Harley).

The third theme, ‘overcoming unforeseen exercise challenges,′ represented the perceived physical and psychological obstacles to exercise-based activities that participants faced. All participants reported a physical or psychological barrier limiting their ability to engage in exercise-based activities, regardless of RTS status. This included dealing with unexpected and prolonged recovery timelines, persistent symptoms, and weight gain.

I still struggle with trying to get rid of weight that I've put on from surgery…it's really tough to come to terms with the fact that as an athlete it's not really that feasible to be ‘oh I'm going to lose weight.′ Because you're doing programs that are supposed to be strengthening. (Freja).

The difficulty of accepting a lengthy recovery timeline highlighted by Ray, and experiencing an ACL tear during an important adolescent milestone as indicated by Hector, reflected the unique challenges of managing an ACL long-term as a youth.

In my mind I thought it would be a few months but then that was quickly, ‘like no this is—this is close to a year′…Cause who, who has a yearlong injury at 15? Like that doesn't make a ton of sense. (Ray)

It [was] kind of weird timing for my injury ‘cause it was right as I was graduating high school. So, my life changed as well. I became less active ‘cause I played on three sports teams in high school…so right now I'm busier…I don't really have time for [sport and exercise-therapy].” (Hector).

Participants that discussed having positive perceptions of recovery (i.e., belief that their knee can return to normal function) appeared to also be more willing to RTS and participate in exercise-based activities despite experiencing physical symptoms. Allison commented that “halfway through the second practice of the day, [I] would start to get a bit sore, but I knew that it was just sore and [there] wasn't actually anything wrong with [my knee].” In contrast, negative perceptions of recovery could influence motivation and adherence to exercise therapy.

It would have been motivating for me if I thought I could recover [100 percent], but I never thought I could…So it felt like I wasn't really working toward anything…I [was told I] couldn't return to my sport. (Hector).

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